Manual of Vascular Medicine by Marie Gerhard-Herman & Aaron Aday

Author:Marie Gerhard-Herman & Aaron Aday
Language: eng
Format: epub
ISBN: 9783030447151
Publisher: Springer International Publishing

Examination

Taking a clear history will be important in making the diagnosis of Raynaud’s phenomenon. The age of onset, frequency and severity of attacks, occupational history, presence of skin tightening, photosensitivity, ulcers, and history of migraine are examples of details that will clarify the diagnosis [10]. Any of the secondary causes may be relevant. Timing of attacks with respect to medication is useful in both diagnosis and treatment. An abrupt change in frequency and severity of attacks in someone with episodic digital pallor since childhood suggests a secondary cause in addition to primary Raynaud’s phenomenon.

Physical examination is done with attention to the secondary causes listed in Table 6.1. The complete physical examination includes thorough pulse examination. A change in pulses with provocative maneuvers, such as elevation of the arm past 90 degrees, may suggest proximal obstruction such as thoracic outlet syndrome. It is important to inspect the nailfold capillaries of the digits looking for dilated vessels or dropout with a magnifying device or ophthalmoscope [11]. Normal nailfold capillaries will appear as regular, symmetric loops, often compared to a picket fence. In contrast, abnormal nailfold capillaries are shown in Fig. 6.2 without magnification. It is useful to acquire pulse volume recording of the digits, typically with pulse oximetry and the addition of warming if well demarcated pallor or cyanosis is present, in order to document improved waveform in combination with resolution of digital pallor. Patients with suspected Raynaud’s phenomenon should never be purposefully exposed to a cold stimulus in the office, as this can trigger severe digital ischemia and even digit loss in some causes.

Figure 6.2Abnormal nailfold capillaries. There is both drop out (arrowheads) and dilation (arrows) seen in the capillary loops. The normal appearance of loops that are regularly placed like a fence has been disrupted. Gently pressing on the nailfold to cause blanching should result in smooth restoration of arteriole blush. In this case, it would result in a spotty, irregular appearance to the restoration of flow

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